RN Case Manager-CSH; LTAC

Job Description

The LTACH Case Manager is responsible for coordinating the care of medically complex patients requiring extended acute care hospitalization. This role ensures optimal care transitions, resource utilization, insurance approvals, and patient advocacy while maintaining compliance with CMS and payer regulations. The Case Manager works closely with physicians, nurses, therapists, and external providers to maximize patient outcomes and facilitate safe discharges to the appropriate level of post‑acute care.

• Care Coordination & Case Management:
  Assess patient medical needs, functional status, and social determinants of health to develop a comprehensive discharge plan.
• Collaborate with physicians, nurses, respiratory therapists, and rehabilitation specialists to monitor progress and adjust plan of care for optimal discharge.
• Ensure early identification of discharge needs and proactively plan transitions of care.
• Participate in weekly interdisciplinary rounds to ensure alignment on treatment goals and discharge planning.
• Discharge Planning & Care Transitions:
  Develop individualized discharge plans based on medical necessity, patient/family preferences, and available post‑acute resources.
• Coordinate placement into inpatient rehab, skilled nursing facilities (SNFs), home health, or long‑term care settings.
• Ensure seamless continuity of care by facilitating communication with post‑acute providers, outpatient services, and community resources.
• Utilization Review & Insurance Coordination:
  Conduct concurrent reviews to ensure patient stays meet LTACH medical necessity criteria.
• Work closely with insurance companies, Medicare, Medicaid, and managed care payers to secure authorizations for continued hospitalization.
• Perform peer‑to‑peer reviews and appeals to address denials and ensure reimbursement for appropriate services.
• Maintain accurate and timely documentation of medical necessity, utilization management, and discharge planning efforts in the electronic medical record (EMR).
• Patient Advocacy & Compliance:
  Serve as a patient advocate, ensuring individuals receive appropriate care that aligns with LTACH‑level medical necessity guidelines.
• Ensure compliance with CMS and hospital accreditation standards.
• Address barriers to care such as social determinants of health, financial limitations, and caregiver support needs.
• Work closely with hospital leadership and quality teams to improve length of stay (LOS), readmission rates, and patient satisfaction.
• Performance Improvement & Data Monitoring:
  Track key metrics such as patient length of stay, readmission rates, denial trends, and insurance approval rates.
• Identify process improvement opportunities to enhance care efficiency and reduce delays in discharge planning.
• Participate in hospital‑wide quality initiatives to improve patient experience and care coordination.
• Utilization of LTRAX for data collection.

Education & Certification

• Required:
  
  RN license.
• Preferred:
  Bachelor’s Degree in Nursing (BSN), Social Work (BSW), or Healthcare Administration.
• Case Management Certification (CCM, ACM, or equivalent) preferred.

Experience

• Required:
  
  Two years of RN experience.
• Preferred:
  Minimum 2–5 years of case management, care coordination, or utilization review experience in an LTACH, acute care hospital, or post‑acute setting.
• Experience with Medicare, Medicaid, commercial insurance, and managed care is highly preferred.
• Strong knowledge of LTACH admission criteria, CMS regulations, and post‑acute care transitions.